Order  Form

To:						From:
BernClare Multimedia Inc.
333 Denison St., Unit 17
Markham, Ontario. 
Canada, L3R-2Z4
Tel:  905-513-2722 
Fax: 905-513-7311

Shipping Address:
   
Name: ____________________________ Company: _________________________

Address: _________________________________________________________________

City: ______________ State/Country: ______________ Zip/Postal: _____________

Phone: _______________________ Fax: _________________________________

E-mail Address: ___________________________________________________________



  Qty 	  Item           	 	 Price (US$/CDN$)          Total

_____	_____________________		____________	_____________

_____	_______________________		____________	_____________

_____	_______________________		____________	_____________

Plus Shipping Cost                                    _____________

Taxes if applied                                      _____________	
		
Total                                                 _____________
								
Method of Payment:

   [ ]  Visa  [ ] Master Card [ ] American Express [ ]  Money Order

   Card #: _______________________________ V-CODE_______ Exp. Date _______ 

   Cardholder's name: ________________________________________

          Signature _________________________		

          Date___________________


               T H A N K   Y O U   F O R   Y O U R   O R D E R !